05 March 2007

It's never a good thing when the radiologist calls you when you are on shift. Radiologists are, to the best of my understanding, subterranean cave dwellers who prefer to communicate with the living via fax machine. When they do call you, it's never to discuss how great the weather is or to offer you free ice cream. No, when they call you it's because in the seclusion of their underground bunkers they have found something Very Bad[tm] on one of your patients.

In this case it was this:I am not a radiologist, but even I can read this. It is a CT scan of the abdomen, formatted in the coronal plane, which can be said to slice the body into "front" and "back" portions. The thing in the upper left hand of the image is the liver, which is infiltrated with several very large tumors. (Below, crudely outlined in red)(see a more-or-less normal liver on coronal CT here)This finding was not a particular surprise to the patient or her family. She had been seen in another ER in the past and had been told she probably had cancer, and had even been referred to an oncologist. She said she was turned away from the oncologist's office because she had no health insurance. I strongly suspect that she was turned away in error by a poorly-informed clerk or receptionist. In my experience, oncologists are the specialty least likely to discriminate based on finances. But there you have it. So, being poor, and, it must be said, not terribly intelligent or assertive, she had simply accepted that it was her fate to have cancer (she didn't even know what type). She kept working her low-wage menial job until the pain prevented her from working any more, and after she had been bed-ridden several days, the family brought her in against her will.

She now has a lethal disease. It is impossible to know whether the original oncologist could have offered her curative treatment. It is impossible to know whether she could have been detected earlier by standard screening techniques. Very likely she simply has a bad disease which was going to kill her regardless of her socioeconomic status. What we do know is this:

She has no health insurance.

As a result, she had no access to primary care and no chance at early detection.

The lack of health insurance presented a barrier to access to care even after diagnosis.

1 comment:

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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